Outline

Background: Zygomycosis is an emerging invasive fungal infection. The disease is difficult to diagnose and even if treated adequately mortality reaches 40%. The majority of patients is immunosuppressed. Standard of care is surgical debridement in combination with systemically active antifungal drugs. Lipid-based amphotericin B is the first-line therapy while posaconazole may be a promising alternative. No controlled trials have been conducted.

Methods: We searched the literature on case reports of zygomycosis treated with posaconazole.

Results: From 2003 to 2009, 59 cases have been published. Diagnosis was based on histology alone in 2 (3.4%), microbiological evidence was found in 39 (66.1%), no data on the diagnostic approach was reported in 18 (30.5%) patients. The most frequent isolates were Rhizopus spp. (16/59; 27.1%), followed by Mucor spp. (12/59; 20.4%). The site of infection was predominantly the rhino-cerebral region in 28 (47.5%), followed by lungs and soft tissue in 7 (11.9%), each. Disseminated infection was found in 8 (13.6%) patients. Treatment modalities were distributed as follows: surgical debridement in 36 (61%), posaconazole monotherapy in 2 (3.4%), combination of posaconazole and lipid-based amphotericin B in 43 (72.9%), other combinations comprised deferasirox, caspofungin, gCSF, and hyperbaric oxygen. Complete response was achieved in 41 (69.5%), partial response in 4 (6.8%), stable disease in 3 (5.1%) patients. Overall mortality was 16.9% patients (lacking data for 1 patient).

Conclusion: In published case reports posaconazole was frequently used as a component of combination treatment. Response and overall mortality appeared better than expected, which could be a possible publication bias. A randomized controlled trial on this unmet medical need is urgently needed.